Open access, freely available online
Policy Forum
Rationing Antiretroviral Therapy for HIV/AIDS
in Africa: Choices and Consequences
Sydney Rosen*, Ian Sanne, Alizanne Collier, Jonathon L. Simon
I
n the past three years, expanding
access to antiretroviral therapy
(ART) for HIV/AIDS has become a
global objective and a national priority
for many countries in sub-Saharan
Africa. Large-scale treatment programs
have been launched in countries
spanning the continent from Lesotho
to Ghana, paid for by domestic funds
mobilized by African governments and
by international donor contributions.
While these funds, which reach into
the billions of dollars, will pay for ART
for many thousands of HIV-positive
Africans, there is almost no chance that
African countries will have the human,
infrastructural, or financial resources
to treat everyone who is in need.
National plans for treatment rollout
typically call for a specific number of
patients to initiate therapy within the
first one or two years of the program.
Though the target patient numbers are
extremely ambitious—often requiring
a 10-fold expansion of services over a
two-year period—they still represent
a minority of those who are eligible
for antiretrovirals on even the most
conservative medical grounds. Table 1
indicates the demand for and supply of
ART in several African countries and
globally, based on starting ART at a
CD4 count of 200 cells/µl or an AIDSdefining illness.
The message of Table 1 is clear:
rationing of ART is already occurring
and will persist for many years to
come. The question facing African
governments and societies is not
whether to ration ART, but how to
do so in a way that maximizes social
welfare, now and in the future.
Inevitably, the social and economic
consequences of rationing a scarce
and valuable resource—treatment for
a life-threatening illness—will vary
widely depending on the rationing
system chosen. In a previous article
[1], we argued that the chances of
The Policy Forum allows health policy makers around
the world to discuss challenges and opportunities for
improving health care in their societies.
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achieving a socially
desirable outcome
from the global
intervention now
being launched
will be higher if
an open publicpolicy debate
is conducted
and policies are
selected that make
transparent the
trade-offs inherent
in any rationing
system. We also
identified a
number of possible
rationing systems
and proposed
several criteria
that could be used
to select among
them. In this
paper, we examine
these issues in
DOI: 10.1371/journal.pmed.0020303.g001
more detail and
Different approaches to rationing HIV drugs will have different
use an expanded
social and economic consequences for African populations
set of criteria to
(Illustration: Margaret Shear)
evaluate several
rationing systems
that already exist in sub-Saharan Africa.
Citation: Rosen S, Sanne I, Collier A, Simon JL (2005)
Systems for Rationing
In economic terms, any policy or
practice that restricts consumption
of a good is a rationing system [2]. A
rationing system restricts demand for
a scarce resource so that it matches
supply [3]. In the marketplace, price
is the basis for rationing: those who
can and are willing to pay the market
price obtain the resource, while those
who cannot or will not pay go without.
Nonmarket goods, such as access to
free or subsidized medical care, are
rationed in a variety of other ways [4].
As used by economists, rationing is a
morally neutral concept. It does not
imply an intent to deprive some people
of a good, but rather describes the
allocation of a resource of which there
is not enough to go around. Non-price
rationing of health care has a long
1098
Rationing antiretroviral therapy for HIV/AIDS in Africa:
Choices and consequences. PLoS Med 2(11): e303.
Copyright: © 2005 Rosen et al. This is an open-access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly
cited.
Abbreviations: ART, antiretroviral therapy; USAID,
the US Agency for International Development; VCT,
voluntary counseling and HIV testing
Sydney Rosen, Alizanne Collier, and Jonathon L.
Simon are at the Center for International Health
and Development, Boston University, Boston,
Massachusetts, United States of America. Ian Sanne
is at the Clinical HIV Research Unit, University of the
Witwatersrand, Johannesburg, South Africa.
Competing Interests: Ian Sanne is the Chief
Executive Officer of Right to Care, a not-for-profit
organization in South Africa that provides treatment
to HIV/AIDS patients.
*To whom correspondence should be addressed.
E-mail: [email protected]
DOI: 10.1371/journal.pmed.0020303
November 2005 | Volume 2 | Issue 11 | e303
Table 1. Targets for Treatment Coverage in Selected African Countries and Globally
Country
Estimated
Number Eligible
for Therapy,
2004
Estimated
Number on
Therapy,
December 2004a
Proportion
Covered,
December
2004
Estimated
Number Eligible
for Therapy,
End 2005b
Target Number
to Be on
Therapy,
End 2005
Expansion
Required
to Achieve
Targetc
Proportion
Covered When
Target Is
Reached
Botswana
Ghana
Kenya
Malawi
Mozambique
Nigeria
South Africa
Uganda
Zambia
Global
75,000
55,000
220,000
140,000
218,000 [34]
558,000
837,000
114,000
149,000
5,800,000
37,500
1,750
28,500
11,000
5,900 [34]
13,500
49,500
45,000
20,000
700,000
50%
3%
13%
8%
3%
2%
6%
39%
13%
12%
94,800
74,200
286,000
188,600
290,000
756,000
1,143,000
141,000
198,800
7,942,000
60,000 [41]
30,000 [41]
95,000 [41]
36,000d [42]
20,800 [34]
100,000 [43]
188,665 [44]
60,000 [41]
100,000 [45]
3,000,000 [40]
1.6
17.1
3.3
3.3
3.5
7.4
3.8
1.3
5.0
4.3
63.3%
40.4%
33.2%
19.1%
7.2%
13.2%
16.5%
42.6%
50.3%
37.8%
Data taken from [40] unless otherwise indicated.
a
This is the midpoint of the high and low estimates made by the World Health Organization [40]. For most countries, it appears to include estimates of patients in the public sector, nongovernmental sector, and private sector.
b
Calculated as the sum of the estimated number eligible for therapy in 2004 [40] plus 6% of the adult HIV-positive population at the end of 2003 as estimated by UNAIDS [46], which is the proportion expected to become eligible over the course
of 2005 due to normal disease progression [5].
c
End 2005 target as multiple of number on therapy, December 2004.
d
Target for July 2005.
DOI: 10.1371/journal.pmed.0020303.t001
history and is widespread and accepted
in many parts of the world, reflecting
the widely held view that access to
health care should be based on some
notion of need, and not determined
solely by ability to pay [4]. At the same
time, non-price rationing is inherently
political. It can be, and often is, used to
channel resources toward or away from
particular groups for reasons unrelated
to their absolute or relative need for
the resource.
The question facing
African governments
and societies is not
whether to ration ART,
but how to do so.
In this paper, we define an ART
rationing system as any allocation of
public resources that prioritizes access
to HIV/AIDS treatment on the basis
of any geographic, social, economic,
cultural, or other nonmedical factor.
This is important, as virtually all
programs will set a medical threshold
for access to treatment, in most cases
having a CD4 count lower than 200
cells/µl or an AIDS-defining illness.
A less conservative medical eligibility
threshold, such as that of the United
States Department of Health and
Human Services, which recommends
that ART be started at a CD4 count
of 350 cells/µl, would dramatically
increase the number of eligible patients
and intensify the need for rationing
[5]. Even with the more conservative
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In many cases, governments will set
explicit criteria for which types of
patients should be eligible for ART
first or at lowest cost. The criteria can
target selected subpopulations directly,
or they can set eligibility requirements
that intentionally give some patients
better access than others. Possible
subpopulations for direct targeting of
treatment include:
Mothers of new infants. Rather
than face an ever-increasing burden of
orphan support, many countries are
making ART preferentially available to
HIV-positive mothers through testing
and treatment at antenatal clinics.
The “MTCT-Plus” initiative (“MTCT”
is mother-to-child transmission, and
“plus” refers to an essential HIV care
package for the mother in addition to
strategies to reduce MTCT), which has
been implemented in many African
countries, is the main example of this
strategy [6].
Skilled workers. African countries
face the loss of vast numbers of
educated or trained workers,
whose skills are vital to maintaining
social welfare, sustaining output,
and generating economic growth.
Human capital can be conserved by
giving treatment priority to nurses,
teachers, engineers, judges, police
officers, and other skilled workers
whose contributions are important
to economic development or social
stability. Botswana [7], Zambia [8], and
Uganda [9] have recently announced
plans to target soldiers, university
faculty and students, and civil servants,
respectively.
Poor people. The social justice
agenda pursued by some governments
and many nongovernmental
organizations argues that the poorest
members of society, who are least likely
to be able to afford private medical
care, should have preferential access
to publicly funded treatment programs
[10]. Means-testing, which can be
applied at the level of the household
or the community and calibrated to
achieve the desired number of patients,
is a common way to ration social
benefits [11].
High-risk populations. The extent to
which ART can curb HIV transmission
is a subject of current debate in the
literature [12,13]. If treatment reduces
the probability of transmission by
suppressing viral load, then a public
health argument can be made for
giving preferential access to high-risk
populations, such as commercial sex
workers, truck drivers, or intravenous
drug users.
Governments can also intentionally
create eligibility requirements that
result in rationing, without specifying
particular target populations. Rationing
systems of this type include:
Residents of designated geographic
areas. One obvious way to limit access
to treatment is to offer it only to those
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November 2005 | Volume 2 | Issue 11 | e303
eligibility threshold now being applied,
however, the figures in Table 1 indicate
that demand for treatment will exceed
supply. In the remainder of this paper,
we will focus our attention on the
nonmedical bases for rationing.
Explicit Rationing Systems
Table 2. Comparison of Rationing Systems
Rationing
System
Effectiveness
(Potential for
Clinical Success)
Cost Savings
(Relative to
Highest Cost
Approach)
Feasibility (Ease of Efficiency
Implementation)
(Human Capital
Preservation)
Medical eligibility
threshold (e.g., CD4
< 200 cells/µm)
Moderate: Limits
treatment to those
already sick, of
whom many will
be too sick to save;
does not protect
patient against
early opportunistic
infections, such as
tuberculosis.
Moderate: Causes
eligible patients to
identify themselves as
a result of symptoms,
but maintains
need to treat early
opportunistic
infections.
Moderate: Requires
access to CD4 count
technology, which
many areas do not
have.
Low: No targeting on
human capital basis
[47].
Mothers of new
infants (MTCT-Plus)
High: Patients are
likely to be diagnosed
relatively early [48].
High: Already in place
under MTCT-Plus;
extension of existing
antenatal clinic
capacity.
Skilled workers
High: Patients are
in a structured
environment and are
likely to be diagnosed
relatively early and to
place a high value on
their ability to work
and earn income.
Moderate: Adherence
has been good where
active adherence
support has been
provided but poor
in less structured
settings [49].
Moderate: Uses
existing antenatal
clinic infrastructure,
but requires widely
dispersed treatment
expertise and
capacity.
High: Tightly defined
population; many
employers already
provide some medical
facilities; may leverage
private sector
resources.
Low: Requires
geographically
dispersed services
to areas with least
existing infrastructure
and to patients
requiring greatest
support.
Low: Patients may be
difficult to identify
and will require
geographically
dispersed services.
Poor people
High-risk
populations
Low: Patients will
be drawn from
marginalized or
mobile populations
and will be difficult to
support.
Residents of
designated
geographic areas
Moderate: Ensures
patient proximity to
services, but patients
may interrupt or
stop treatment when
they must leave the
catchment area.
Moderate: Copayment may increase
motivation to adhere,
but many patients will
stop treatment when
their own funds run
short.
High: Limits treatment
to those most likely to
adhere or who have
demonstrated high
adherence.
Ability to co-pay
Commitment to
adherence
High: Minimizes total
infrastructure costs.
Equity (Equitable
Access)
Rationing
Potential (Ability
to Limit Demand)
Low: Too many
patients are eligible,
even using the most
conservative medical
eligibility threshold.
High: Reduces societal
burden of orphan
care and promotes
parental investment in
future human capital.
Moderate: All HIV+
individuals are equally
eligible, but favors
those who have
access to laboratory
testing, who may be
wealthier or urban,
and may favor those
infected earliest, who
may be from specific
groups.
Low: Excludes all men;
excludes women not
of child-bearing age
or choosing not to
have children.
High: Successful
implementation by
many employers
already underway.
High: Preserves
critical skills
needed to maintain
development.
Low: Treats the
elite; excludes the
poor, unemployed,
unskilled.
Moderate: Some
capacity for means
testing is required.
Infrastructure may
not be adequate in
poorest areas.
Low: Targets relatively
economically
unproductive
subpopulations,
though may also
avoid subsidizing
wealthier populations.
Moderate:
Extends access to
subpopulations that
would not otherwise
have it, but excludes
middle and upper
socioeconomic tiers.
Low: Most people in
sub-Saharan Africa
are poor.
Moderate: Some
populations will be
relatively easy to
reach but others
will be outside the
existing health care
system.
Moderate: Easy
to establish, but
difficult to prevent
excluded patients
from migrating into
catchment areas.
Moderate: Has the
potential to protect
economically active
populations, such
as truck drivers or
miners.
Moderate:
Extends access to
subpopulations that
would not otherwise
have it, but excludes
those who lead lowrisk lives.
Moderate: Equal
access for everyone in
catchment areas, but
excludes everyone
outside catchment
areas.
High: The high-risk
population tends to
be relatively small.
Moderate: Cost
to public sector is
reduced, but cost to
patients is higher.
High: Easy to
implement and
already underway in
many places.
High: Some costs for
adherence support,
but most strategies
are inexpensive and
may reduce need for
expensive second-line
or salvage therapy.
Moderate: Requires
that adherence
support be widely
available.
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1100
Moderate: Could
be targeted to
economically
important areas,
but no individual
targeting within
catchment areas.
High: Reaches
employed persons;
conserves public
resources to allow
more patients to be
treated.
Moderate: No
targeting on human
capital basis, but
could exclude those
who are personally
irresponsible.
Low: Excludes those
too poor to pay.
High: Equal access to
all potential patients.
Moderate: Excludes
more than half the
population but retains
eligibility for women
of reproductive age,
who have the highest
HIV prevalence.
High: There are
relatively few skilled
workers in most
African countries.
High: Can designate
catchment areas to
encompass only the
number of eligible
patients for which
treatment “slots” are
available.
High: Relatively few
people can afford
even a modest copayment.
Low: Up to 100% of
medically eligible
patients could qualify.
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Table 2. Continued
Rationing
System
Effectiveness
(Potential for
Clinical Success)
Cost Savings
(Relative to
Highest Cost
Approach)
Feasibility (Ease of Efficiency
Implementation)
(Human Capital
Preservation)
Equity (Equitable
Access)
Rationing
Potential (Ability
to Limit Demand)
Access to testing
Moderate: Could favor
patients who actively
seek testing and are
thus more motivated.
Moderate: Requires no
additional action to
identify patients.
High: Some early
successes with VCT
campaigns suggest
feasibility.
Moderate: Favors
target populations for
VCT campaigns, who
may or may not be
efficient populations
to treat.
Moderate: Favors
some but does not
exclude others.
Patient costs
Moderate: Ensures
patient proximity to
services, but distant
patients may stop
treatment when they
can no longer afford
transport.
Moderate: No effort to
prioritize patients but
could encourage early
diagnosis.
High: Minimizes
infrastructure needs
and requires no
additional action to
identify patients.
High: Default; requires
little action.
Low: Excludes those
too poor to pay for
transport or who live
in remote areas.
High: Requires no
additional action to
identify patients.
High: Default; requires
little action.
Moderate: Everyone
has access, but system
is highly susceptible
to queue-jumping.
Moderate: No effort
to prioritize patients;
very sick patients
could be stuck in
queue.
High: Requires no
additional action to
identify patients.
High: Default; requires
little action.
Moderate: Favors
those who can afford
costs, who may be
income earners, but
also favors those who
happen to live closest
to facilities.
Low: No targeting on
human capital basis;
could favor those who
were infected first and
are at greatest risk.
Low: Favors patients
with low opportunity
cost of time (e.g., the
unemployed) and
wastes time of those
who participate.
Moderate: Patient
numbers could be
reduced by limiting
access to VCT, but
VCT is also an
important prevention
strategy and is being
expanded rapidly.
Moderate: If patient
costs are high, few
people will be able
to afford treatment,
but numbers will be
difficult to control or
predict.
High: Door can
be closed once all
treatment “slots” are
filled.
Moderate: Everyone
has access, but system
is highly susceptible
to queue-jumping.
High: Queue can
be closed once all
treatment “slots” are
filled.
First come, first
served
Queuing
DOI: 10.1371/journal.pmed.0020303.t002
who reside in specified geographic
catchment areas [14]. These areas
can be distributed around the
country, centered in regions of high
HIV prevalence, or concentrated in
urban centers or politically important
regions. Excluding patients who do
not live within the designated areas
may not be feasible, but most patients
will not be able to afford the cost
of regular transport or permanent
relocation.
Ability to co-pay. If patients are
required to contribute even a small
share of the cost of treatment, the
number who can access therapy is likely
to fall dramatically. Governments could
in principle match supply and demand
by setting and adjusting the level of
co-payment required. The obvious
outcome is a rationing system that
favors the upper socioeconomic tiers of
patients, who likely include the majority
of skilled workers. In some societies
men will also have preferential access
when a cash payment is required [15].
A drawback of requiring co-payment is
that poorer patients may stop therapy
because they run out of funds. This is
the reason for stopping cited by nearly
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half of all non-adherent patients in a
recent study in Botswana [16].
Commitment to adherence to
therapy. Adherence to treatment
regimens has been found to be the
most important determinant of the
success of ART at the individual
patient level [17]. One way to
improve the success of a large-scale
treatment program, while at the
same time limiting access, could
therefore be to restrict therapy to
patients who are judged to have the
ability and willingness to adhere or
who demonstrate high adherence
after initiating therapy. Results of
pilot projects suggest that requiring
attendance at pre-treatment counseling
sessions helps to screen for adherence
commitment, for example [18].
Implicit Rationing Systems
The alternative to specifying explicitly
who will have priority access to resources
is to allow implicit rationing systems to
arise. These can be thought of as the
default conditions that will prevail in the
absence of explicit choices.
Access to HIV testing. Voluntary
counseling and HIV testing (VCT)
1101
is typically the entry point into an
HIV/AIDS treatment program. If
some subpopulations, such as youth
or particular occupational groups, are
targeted for HIV education and VCT
services or promotion campaigns, they
will have an advantage over others in
seeking treatment, as will those who
simply live closer to VCT facilities [19].
Patient costs. Most countries will
scale up their treatment programs
incrementally, at first offering services
at only a few facilities before gradually
adding more. Ghana started with four
public treatment sites in 2004, for
example, but is aiming to have 16 in
operation by the end of 2006 [20]. For
most patients, bus or taxi fare will be
required for regular trips to the clinic,
and each trip will take up a good deal
of time. Previous research has found
that indirect costs due to travel time
and transport play an important role
in limiting access to medical care
[21–24]. Unless transport is subsidized,
limiting the number of service sites
will effectively ration treatment to
those who live nearby and to better-off
households that have the resources to
travel.
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First come, first served. In the
absence of any other requirements,
most facilities are likely to treat everyone
who is medically eligible, until the
supply of drugs, diagnostics, or expertise
runs out. Patients who arrive after that
happens may be put on a waiting list,
sent to another facility, or simply sent
away. This approach, which reflects an
absolute shortage of treatment “slots,” is
likely to favor three groups of patients:
those who are already paying privately
for antiretroviral drugs and shift over
to publicly funded treatment once it
is available; those who develop AIDSrelated symptoms first, in most cases
because they were infected earliest; and
the few HIV-positive individuals who do
not yet have AIDS but have taken the
initiative to go for a test and know their
own status.
Queuing. One of the most common
ways to ration scarce resources is
the time-honored, time-consuming
tradition of queuing. While it is
possible to create a waiting list that
keeps track of individuals’ places in
line, in many African countries the
queue is a literal line outside the
clinic door. Such queuing will favor
patients whose opportunity cost of time
is low [23]. This group is likely to be
dominated by unemployed men and
by women who can bring their small
children with them. It may penalize
employed persons and farming
households that face a high seasonal
demand for labor.
No matter what system is used,
informal and/or illicit arrangements
can often be made that give
preferential access to treatment to
those with social, economic, or political
influence. In all of the implicit systems,
and in some of the explicit ones,
there will very often be a high degree
of queue jumping. Elites capture a
disproportionate share of resources in
all countries; in developing countries,
where enforcement of rules tends to
be weak and informal arrangements
common, it is safe to assume that
members of the elite who are medically
eligible for therapy will find a way to
get it. De facto rationing on the basis
of social or economic position will thus
occur. It is the phenomenon of queue
jumping that turns what appear to
be equitable, if inefficient, rationing
systems, such as first-come, first-served,
into an inequitable and inefficient
approach.
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Many other potential criteria for
rationing ART have been proposed or
are in use [11,14,25,26]. Treatment
access could be targeted, for example,
to young people (because they
respond best to the therapy and have
their most productive years ahead of
them); families of current patients (to
promote adherence); those with debts
(so that the loan default rate does not
increase); patients with tuberculosis (to
suppress transmission of tuberculosis);
or children (who are least able to
protect themselves).
Effectiveness. Does the rationing
system produce a high rate of
successfully treated patients?
“Successful treatment” could be
defined as a fully suppressed viral
load or high CD4 count over a
sustained period of time. It might also
incorporate some measure of viral
resistance to the drugs. We assume that
early diagnosis and high adherence
improve effectiveness and that patient
motivation improves adherence, but
level of education and socioeconomic
status do not [27].
Cost savings. Is the cost per patient
treated low, compared to other
approaches? Cost is characterized
in this way to maintain internal
consistency: a rating of “high” in
this domain is desirable, as it is for
all other criteria. Cost is defined
broadly, to incorporate costs incurred
by patients, providers, insurers, and
the public health system, including
the identification of medically
eligible patients and management of
opportunistic infections, side effects,
and treatment failure.
Feasibility. Are the human and
infrastructural resources needed for
implementation available? We define
an approach as feasible if there are no
obstacles to carrying it out that appear
to be insurmountable under typical
conditions in sub-Saharan Africa.
Economic efficiency. To what extent
does the system mitigate the longterm impacts of the HIV epidemic
on economic development? AIDS
has the potential to affect economic
development in many ways [28]. We
focus on human capital accumulation,
where human capital is defined as the
accumulated skill, knowledge, and
expertise of workers [29].
Social equity. Do all medically
eligible patients, including those from
poor or disadvantaged subpopulations,
have equal access to treatment? We
define “equity” as equitable access
for all at the current time, not
redistribution of resources to redress
past injustices, and we assume that a
system’s susceptibility to queue-jumping
reduces its equity.
Rationing potential. Will the chosen
system sufficiently reduce the number
of patients? The purpose of any
rationing system is to match demand to
the available supply.
Impact on HIV transmission. To
what extent does treatment reduce
HIV incidence? Preferentially treating
those who are likely to transmit the
virus could reduce HIV incidence more
than treating those who are not likely
transmitters [13,30].
Sustainability. Can the system be
sustained over time? This criterion
pertains to the durability of the
source of funding. We assume that
donor support will hold out for some
time but will ultimately ebb, leaving
national governments responsible
for an increasing share of the costs of
treatment [31].
Effect on the health care system.
How does the system for allocating
ART affect the country’s health care
system as a whole? The choice of
rationing strategies could influence
whether expanding treatment access
will strengthen general health services
for poor communities or drain
resources from non-HIV health care
to meet the demand for ART, further
crippling general health services.
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Evaluating the Systems
The different approaches to rationing
ART described above will inevitably
have very different social and economic
consequences for African populations.
In this section, we assess the rationing
systems’ probable outcomes using
criteria that capture most of the
principles that governments use to
evaluate policies and social investments.
They are by no means the sole criteria
of interest, nor should they necessarily
be given equal weight. We propose
them only as a starting point for
thinking about the consequences of
alternative approaches.
Implicit rationing is not
likely to maximize social
welfare.
To demonstrate how one might
evaluate alternative rationing
strategies, Table 2 uses the first six
of these criteria to compare each
of the rationing systems described
above. The table omits the impact
on HIV transmission and the impact
on resistance, because there is little
agreement on how the treatment
of different populations is likely
to affect these outcomes. It also
omits the two long-term “systems”
criteria—sustainability and effect on
the health care system—because most
treatment programs are so new that
even informed speculation is difficult
to offer.
There are several limitations to
the analysis presented in Table 2.
First, we do not “know” the outcomes
of the strategies described above,
because most of them have either not
yet been tried or, if tried, have not
been evaluated. Prior experience in
delivering health care in sub-Saharan
Africa suggests that some of our
assumptions and ratings are correct.
We are confident, for example, that
an implicit rationing system based on
queuing will result in queue-jumping,
and therefore be inequitable. We
are also confident that targeting
skilled workers will improve labor
productivity and therefore promote
economic efficiency. Our ratings of
some of the other systems, in contrast,
are largely speculative. Table 2 also
cannot capture the possibility that
outcomes will vary by country, setting,
or context.
A second limitation involves the
criteria we selected for evaluation.
We applied six criteria that we believe
capture the key considerations in
designing an HIV/AIDS treatment
program, and we identified but did
not apply three others that could alter
the overall outcomes. Undoubtedly,
there are other criteria that also
matter. We also could not account
for potential interactions among the
criteria. Cost and feasibility are clearly
related, for example; at some level of
cost, any system could be considered
feasible. Many would argue that
social equity is essential to sustainable
economic development, and that
efficiency and equity cannot therefore
be separated. While we recognize that
these relationships exist, neither data
nor experience allows us to address
them here.
PLoS Medicine | www.plosmedicine.org
Conclusions
During the initial months of existing
ART programs in sub-Saharan Africa,
limited access to health care services
and widespread reluctance to be
tested for HIV or enroll in treatment
programs have greatly limited patient
numbers [32,33]. This phenomenon,
for as long as it persists, may prevent
demand from exceeding supply, and
no rationing will be necessary. There
are already some situations, however,
in which patients demanding access
to care have overwhelmed available
resources [34]. Even under the most
optimistic scenarios for reaching
universal coverage, there will be a
period of at least several years when
treatment is scarce.
Rationing of medical care is not
a new phenomenon, nor is it by any
means limited to developing countries.
Waiting lists, whether for specific
procedures, organs for transplant, or
experimental treatments, are common
in North America and Europe. Many
state governments in the US are
explicitly limiting access to more
expensive AIDS drugs [35]. The HIV/
AIDS crisis in Africa is simply bringing
the need for rationing into stark relief.
There is no single rationing system,
or combination of systems, that will
be optimal for all countries at all
times. Table 2 highlights the trade-off
between economic efficiency and social
equity: rationing systems that rate high
in terms of efficiency generally rate
low in terms of equity. African societies
will place different weights on the
values inherent in goals such as equity
and efficiency, and decisions about
rationing will be made at multiple levels
of the health care system. International
funding agencies have already begun
to express their priorities through the
amounts and conditions of their grants.
Ministries of health will set policies
that reflect national priorities, followed
by district and local departments of
health. Even individual health care
workers, such as nurses at clinics where
antiretroviral drugs are available but
scarce, will be forced to ration access to
patients who meet the clinic’s or their
own criteria [36].
Because access to antiretroviral drugs
is a matter of life or death for patients
with AIDS, the choice of rationing
systems matters deeply. African
governments can take one of two
courses: ration deliberately, on the basis
1103
of explicit criteria, or allow implicit
rationing to prevail. Implicit rationing
is not likely to maximize social welfare,
nor does it allow for transparency
and accountability in policy making.
We believe that the magnitude of the
intervention now underway and the
importance of the resource allocation
decisions to be made call for public
participation, policy analysis, and
political debate in the countries
affected. Several proposals have been
made for how such processes could
be carried out ([11,26,38,39]; A.
Acharya, unpublished data). In the
absence of such processes, decisions
about access to treatment will be made
arbitrarily and will, most likely, result
in inequity and inefficiency—the
worst of both worlds. Governments
that make deliberate choices, in
contrast, are more likely to achieve a
socially desirable return from the large
investments now being made than are
those that allow queuing and queuejumping to dominate. Countries that
promote an open policy debate have
the opportunity to ration ART in a
manner that sustains both economic
development and social cohesion—in
the age of AIDS, the best of both
worlds. Acknowledgments
Funding for the research presented in this
paper was provided by the South Africa
Mission of the US Agency for International
Development through the Child Health
Research Project, G/PHN/HN/CS, Global
Bureau, the US Agency for International
Development (USAID), under the terms of
Cooperative Agreement No. HRN-A-00-9690010-00, the Applied Research on Child
Health Project, and by the South Africa
Mission of USAID through Cooperative
Agreement No. 674-A-00-02-00018 to Right
to Care. The opinions expressed herein are
those of the authors and do not necessarily
reflect the views of USAID. The funding
agency did not influence the conduct or
outcomes of the analysis or exercise any
editorial control over this paper.
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